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Page 8 of 10 de Divitiis et al. Mini-invasive Surg 2020;4:75 I http://dx.doi.org/10.20517/2574-1225.2020.66

meningioma. The rostral and caudal poles were identified; the tumor was debulked and dissected from
the arachnoidal adherences. The dorsal dural attachment was visualized and the tumor was released. En
bloc gross total resection was achieved with no intra-operative complications. The exoscope visualization
provided excellent images quality, both during the extradural and intradural surgical steps. After initial
positioning of the camera 30 cm above the surgical field, repositioning was never required. Zooming
and focusing were adjusted after dural opening; zoom was further increased during tumor dissection.
Histological diagnosis confirmed a WHO I spinal meningioma. Clinical and radiological follow-up at three
months demonstrated total removal of the meningiomas and walking improvement. Further treatment for
the other lesions is planned.

CONCLUSION
Vitom-3D has recently entered the field of neurosurgery and, in selected case, it represents an alternative
visualization tool to the operating microscope. Working environment ergonomics and trainees learning
experience are the most relevant benefits associated with the use of exoscope. The optical properties make
it best suited for spinal procedures rather than intracranial surgery, both for degenerative diseases and
tumors removal. In particular, spinal meningiomas removal under skin-to-skin Vitom-3D visualization
only seems feasible, efficient, and safe. Indications to the use of Vitom-3D greatly depend on tumor size,
consistency, relationship to surrounding neurovascular structures, and surgeon’s experience. Switching to
the operating microscope, if deemed safer, should always be considered. Further studies, including larger
homogenous series, are needed to better define advantages and limitations of the exoscope in meningiomas
surgery as compared to the operating microscope.

DECLARATIONS
Authors’ contributions
Made substantial contribution to conception of the study: de Divitiis O, Denaro L
Prepared the manuscript draft: d’Avella E, Baro V
Responsible for images and supplementary material: Sacco M, Somma T
Critically revised the final version of the manuscript: de Divitiis O, Turgut M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not Applicable.

Copyright
© The Author(s) 2020.